Virtual Skin Consultation

Virtual Skin Consultation

with France Di Paola, licenced AlumierMD Skincare Specialist
Full Name*

First NameLast Name
Cell Number
Alternate Phone Number
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear of our services?*

Online SearchYelpFacebookInstagramReferralOther
If referred to us, please list name.
What are your skincare goals?
ABSOLUTE CONTRAINDICATIONS*

Currently using Accutane in the last six monthsPregnant or nursing/lactatingHistory of cold sores (Herpetic breakout)AllergiesSkin cancer / lesions removed in area of treatmentCurrently undergoing CHEMO or on oral Chemo medicationAutoimmune illnessesNone of these apply to mePlease elaborate on any which apply to you using the "OTHER" sectionOther
RELATIVE CONTRAINDICATIONS*

Currently using topical prescription medication on the area of treatmentCurrently using prescription or non prescription Retinols, or Retin-A, Tazorac or AHA/BHAI have a medically diagnosed skin issue(s)I have had an adverse reaction from skincare productsNone of these apply to mePlease elaborate on any which apply to you using the "OTHER" sectionOther
Do you have any of the the following skin conditions? Describe your skin type*

Acne / Acne ScarringHormonal Acne / Adult AcneBlemishes / Clogged Pores / Bumps under skinTextural ChangesEnlarged PoresUneven Skin TomeHyperpigmentation / Melasma / Sun DamageBroken Capillaries (Tiny Blood Vessels)Sensitivity / IrritationRedness-Prone / RosaceaWrinkles / Fine LinesAging SkinOily / Excessive OilCombination / Oily T-ZoneNormalDry / DehydratedThick SkinThin SkinNone of these apply to meOther
In your own words, please describe your skin:
Please take a FULL FACE photo
Please take a RIGHT SIDE FACE photo
Please take a LEFT SIDE FACE photo
Have you had a professional facial or skin treatment before?*

YesNo
If yes, how long ago and what kind of facial/treatment?
What skincare products do you currently use?*

Cleanser / Face WashBar of SoapFace Scrub / ExfoliantsTonerTarget Serums; i.e. for anti-aging, acne, rosacea, oily skin, hyperpigment/melasmaMoisturizerSunscreenEye ProductsLip ProductsFacial Mask TreatmentsNone of these apply to meOther
Have you tried any cosmetic exfoliants or cellular renewal products such as:*

RetinolLactic AcidsAHA/BHAGlycolic AcidsEnzymesNone of these apply to meOther
What do you enjoy using the most?*
What drives your decision when choosing products; texture, scent, clean science/natural, price point, luxurious feel?
What is your ethnic background?
Does your skin change seasonally?
What has been your experience in the last year with your current choice of skincare and are these products taking care of your immediate skin concern(s)?*
How much sun are you exposed to now or in the past years?*

A lotA lot in the past, not so much nowMinimalAverageVery littleI'm outdoors a lot
Do you wear sunscreen?*

Yes every dayYes, but not on a regular basisOnly when I'm doing an outdoor activityOnly when at the beach or poolNo
Which services if any, would you like to know more about for your skin?*

Pigmentation CorrectionBroken Capillary CorrectionBlemish Removal for Raised BumpsCollagen BoostingSkin TighteningBotoxFillersNon Invasive Skin TreatmentsHome Care ProductsI'm not sure and would like your adviceOther
Your skin is an investment...not an expense.
Thank you for providing your information. As part of your client profile, it is kept strictly confidential. With your consent, we will send you an invitation to the AlumierMD web portal, where you will have access to your customized skincare regimen chosen specifically for the skin concern(s) you have listed above / or which will be discussed during a one-on-one Virtual Skincare Consultation.
I consent to sharing this information with France Di Paola, GlowDerma Team and AlumierMD Labs and give permission to communicate with me via email.*

Yes I agree
I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation when using medical grade ingredients which are of higher concentration than over the counter / drug store cosmetics and I release the Skincare Specialist from liability and assume full responsibility thereof.
Clear
France Di Paola, AlumierMD licenced Skincare Specialist

ALL SKIN RADIANCE a subsidiary of

CONFIDENT IMAGE CHEZ FRANCE

36 Hiscott St., St. Catharines, ON L2R 1C8

info@allskinradiance
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